Michelle Doll

Touchless Technologies for Decontamination in the Hospital: a Review of Hydrogen Peroxide and UV Devices

Reduction of microbial contamination of the hospital environment is a challenge, yet has potential impacts on infection prevention efforts. Fumigation and UV light devices for environmental cleaning have expanded into the health care setting with the goal of decontamination of difficult to clean or overlooked surfaces. In an era of increased scrutiny of hospital-acquired infections, increasingly, health care centers are adopting these “touchless” cleaning techniques as adjuncts to traditional manual cleaning. The evidence for improved clinical outcomes is lacking; yet, the experience with these devices continues to accumulate in the literature. We review the recently published data related to the use of hydrogen peroxide and UV light-based decontamination systems for cleaning of hospital rooms. Touchless cleaning technologies may provide an incremental benefit to standard practices by limiting cross-transmission of pathogens via environmental surfaces, though evidence of prevention of infections remains limited.

Acceptability and Necessity of Training for Optimal Personal Protective Equipment Use.

Healthcare workers routinely self-contaminate even when using personal protective equipment. Observations of donning/ doffing practices on inpatient units along with surveys were used to assess the need for a personal protective equipment training program. In contrast to low perceived risk, observed doffing behaviors demonstrate significant personal protective equipment technique deficits. Infect Control Hosp Epidemiol 2017;38:226-229.

Infection Prevention in the Hospital from Past to Present: Evolving Roles and Shifting Priorities

Hospital epidemiologists are vital components of integrated health centers. This central place in the healthcare landscape has rapidly evolved over a half century. Early hospital epidemiologists possessed a visionary focus on patient safety many decades prior to the quality revolution of the 1990s. A systematic and scientific approach to infection prevention has facilitated the evolution of hospital epidemiology, along with advances in technology, and increasing public attention to infectious complications in the hospital. Currently, the growing expansion of tasks and moving regulatory targets strain existing resources. These challenges threaten to limit the effectiveness of some infection-prevention activities, while also providing important opportunities for improving care. It will be increasingly important to advocate for appropriate resources to address a diverse set of changing infection prevention priorities.

Environmental cleaning and disinfection of patient areas

The healthcare setting is predisposed to harbor potential pathogens, which in turn can pose a great risk to patients. Routine cleaning of the patient environment is critical to reduce the risk of hospital-acquired infections. While many approaches to environmental cleaning exist, manual cleaning supplemented with ongoing assessment and feedback may be the most feasible for healthcare facilities with limited resources.

Ultraviolet-C light as a means of disinfecting anesthesia workstations

HighlightsThe anesthesia workstation is a reservoir for pathogenic organisms potentially associated with surgical site infections (SSIs).Carriers inoculated with a known concentration of either S. aureus, E. faecalis, or Acinetobacter baumannii. were placed on 22 high‐touch surfaces of the anesthesia workstation and exposed to UVC light using the Tru‐D UVC device.All experimental trials, compared to controls, exhibited a bioburden greater than 2 log versus controls, regardless of whether the surfaces received direct exposure to the UVC light or not. Background: Anesthesia workstations (AWs) are a reservoir for pathogenic organisms potentially associated with surgical site infections. This study examined the effectiveness of the Tru‐D SmartUVC device (Tru‐D LLC, Nashville, TN) on bioburden reduction (BR) on AWs. Methods: Strips of tissue inoculated with a known concentration of either Staphylococcus aureus, Enterococcus faecalis, or Acinetobacter sp were placed on 22 high‐touch surfaces of an AW. Half of the AW surfaces received direct ultraviolet (UV) light exposure and half received indirect exposure. Two inoculated strips, in sterile tubes outside of the room, represented the control. Trials were conducted on AWs in an operating room and a small room. Strips were placed in a saline solution, vortexed, and plated on blood agar to assess BR by the number of colony forming units. Results: All experimental trials, compared with controls, exhibited a BR >99%. There was a significantly greater reduction of E faecalis colony forming units in the operating room AW under direct exposure (P = .019) compared with indirect exposure. There was no significant difference in reduction when comparing AWs between rooms. Conclusion: Regardless of room size and exposure type, automated UV‐C treatment greatly influences BR on AW high‐touch surfaces. Hospitals instituting an automated UV‐C system as an infection prevention adjunct should consider utilizing it in operating rooms for BR as part of a horizontal infection prevention surgical site infection‐reduction strategy.

Deployment of a touchless ultraviolet light robot for terminal room disinfection: The importance of audit and feedback

HighlightsTerminal disinfection with ultraviolet device in Clostridium difficile rooms.Compliance improved from 20% to 100% during a 25 month study.Audit and feedback utilized to drive compliance of ultraviolet disinfection. &NA; Touchless ultraviolet disinfection (UVD) devices effectively reduce the bioburden of epidemiologically relevant pathogens, including Clostridium difficile. During a 25‐month implementation period, UVD devices were deployed facilitywide for the terminal disinfection of rooms that housed a patient who tested positive for C difficile. The deployment was performed with structured education, audit and feedback, and resulted in a multidisciplinary practice change that maximized the UVD capture rate from 20% to 100%.

The Increasing Visibility of the Threat of Health Care Worker Self-contamination.

The vulnerability of health care workers to acquisition and propagation of infectious agents has received global attentionbecause of recent outbreaks of highly communicable and fataldiseases, includingEbola virusdiseaseandsevereacute respiratory syndrome. The emergenceof thesehigh-profilepathogenshaspromptedcalls for better personal protective equipment (PPE), specifically, masks, gowns, and gloves, to protect health care workers and patients. In this issue of JAMA Internal Medicine, Tomas and colleagues1 provide a timely addition to the existing literature on the limitations of our current PPE. In a series of related studies thatusepreviouslydescribedmethods2 tosimulatecontaminatedPPE, the investigatorsconvincinglydocumentahigh frequencyofhealthcareworkerself-contaminationwhenusing PPE. Thebulk of their data come from435 simulations of donning and/or doffing of gowns and gloves contaminatedwith a fluorescent lotion: 234were soiled glove simulations, and 201 were soiled gown simulations. Almost half (46.0%) of these simulations resulted in health care worker self-contamination of skin or clothing. Specific sites of contamination varied butmost commonly involved thehands during glove removal and the neck during gown removal. Furthermore, 39.5% of participantswereobserved tobeusing improper techniqueby 2 independent observers who compared participants’ techniques with the Centers for Disease Control and Prevention (CDC) procedure3 for donning and/or doffing PPE. The probabilityof self-contaminationwasmuchgreaterwhenusing improper technique (70.3%vs 30.0%). In a separate experiment, the investigators document that fluorescent lotion contamination is a reliablepredictor ofmicrobe contaminationbymixing bacteriophage MS2 to the solution and performing additional simulations; contamination with the lotion vs MS2 was not statistically different.1 Theseresultshaveclear implications for thesafetyofhealth careworkers and the spread of hospital-acquired infections. It has been documented that higher levels ofmicrobial contamination of hospital surfaces lead to higher rates of health care worker contamination with multidrug-resistant organisms.4 Because environmental bioburden is a concern for the crosstransmission of hospital-acquired pathogens, the microbial burden of health care worker hands and apparel represents another element in this equation. Collectively, this increased contamination of the animate and inanimate environment contributes to the risk of hospital-acquired infections. Tomas et al report a potential for improvement in the intervention portion of their study. A subset of participants were able to decrease self-contamination after a training session that includeda 10-minute instructional videowith structured practice using simulated contamination with fluorescent lotion. The authors found that this real-time assessment with “immediate visual feedback” was able to reduce health careworker self-contaminationby68%(from60.0%to18.9%). This reductionwassustainedat 1-and3-monthfollow-upswith no additional training.1 A standardized training procedure for health care workers on the recommended techniques for donning and/or doffing gowns and gloves is long overdue. The training should include educational context, proficiency monitoring, and feedback. The “immediate visual feedback”usedbyTomas et al1 appears to be particularly effective in altering staff behaviors.However, a standard,accepted,andvalidatedtrainingprogram has unfortunately not been developed, and debate remains as to what constitutes best practice for donning and doffing. The CDC’s recommendations are widely adopted. However, even theCDC’sprocedureshavebeen foundbysome to be insufficient.2 In fact, notwithstanding the significant benefit of the intervention reported in this issue, therewas still 30% residual contamination of intervention participants.1 Double gloving and cleaning of gloves before doffing have beensuggestedasadditions to thecurrentCDCpractices,1,2 but evidence of the effectiveness of these interventions for routine patient care interactions is lacking. Any standardized procedure and training program will need to take into account the individual health care worker’s comfort, scope of duty, previous training, and typical workload. Minute attention to details of donning and/or doffing is of vital importancetowardthegoalofprotectingpatientsandstaff, yet these efforts are undercut by poor adherence to the use of PPE.Healthcareworker fatiguewithcontactprecautions iswell documented,withdeficiencies increasinginproportiontoworkload and percentage of patients adhering to precautions in a givenunit.5,6 Inaddition,handhygienehasbeenreportedtodecreasewith increased glove use.7 Therefore, a prioritization of patients for contact precautions is needed to optimize adherencewithgloveandgownprecautions in the instanceswhen it will be most important. Patients should be targeted for isolation based on the presence of highly transmissible, nonendemicorganismsassociatedwithsignificantmorbidityandmortality.Aselectiveapproachto isolationmaximizesstaffattention to the transmission risk posedbypriority organisms and limits theadverseeffectsof contactprecautionsonpatientsandstaff. In the absence of such anorganism, efforts are best focusedon the fundamental horizontal infection control strategies that should be used for every patient care interaction. Last, the residual contamination of health care workers, even with optimal donning and/or doffing technique, highlights the ongoing importance of hand hygiene on completion of doffing activities. Of interest, Tomas et al applied their Related article page 1904 Health Care Personnel Contamination During Protective Equipment Removal Original Investigation Research

Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus : An Interrupted Time Series Analysis

OBJECTIVETo investigate the impact of discontinuing contact precautions among patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) on rates of healthcare-associated infection (HAI). DESIGN Single-center, quasi-experimental study conducted between 2011 and 2016.METHODSWe employed an interrupted time series design to evaluate the impact of 7 horizontal infection prevention interventions across intensive care units (ICUs) and hospital wards at an 865-bed urban, academic medical center. These interventions included (1) implementation of a urinary catheter bundle in January 2011, (2) chlorhexidine gluconate (CHG) perineal care outside ICUs in June 2011, (3) hospital-wide CHG bathing outside of ICUs in March 2012, (4) discontinuation of contact precautions in April 2013 for MRSA and VRE, (5) assessments and feedback with bare below the elbows (BBE) and contact precautions in August 2014, (6) implementation of an ultraviolet-C disinfection robot in March 2015, and (7) 72-hour automatic urinary catheter discontinuation orders in March 2016. Segmented regression modeling was performed to assess the changes in the infection rates attributable to the interventions.RESULTSThe rate of HAI declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 (P=.76) and 6.25 (P=.21) per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days (P=.23) for device-associated HAI following discontinuation of contact precautions.CONCLUSIONThe discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. This approach may represent a safe and cost-effective strategy for managing these patients.Infect Control Hosp Epidemiol 2018;39:676-682.

Carbapenem-resistant Enterobacteriaceae at a low prevalence tertiary care center: Patient-level risk factors and implications for an infection prevention strategy

Highlights:Carbapenem‐resistant Enterobacteriaceae (CRE) continues as a global threat to hospitals.Recognizing patient‐level risk factors may help enhance CRE surveillance.Antimicrobial stewardship programs play a critical role in combating CRE. &NA; Limited treatment options and a growing global threat from carbapenem‐resistant Enterobacteriaceae (CRE) infections illustrate the importance of understanding the epidemiology of CRE. Using a retrospective chart review and point prevalence testing demonstrated specific patient risk factors for CRE‐positive clinical cultures in a tertiary medical center with a low CRE prevalence.

Inappropriate Antibiotic Use and Gastric Acid Suppression Preceding Clostridium difficile Infection.

Medical Center, Minneapolis, Minnesota; 2. Minnesota Department of Health, St. Paul, Minnesota; 3. University of Minnesota Health, Minneapolis, Minnesota; 4. Department of Medicine, Infectious Disease Division, University of Minnesota, Minneapolis, Minnesota. Address correspondence to Jeana Houseman, MHSA, Infection Prevention Department, University of Minnesota Medical Center, 420 Delaware St SE, Suite C370-1, Minneapolis, MN 55455 (Jhousem1@fairview.org). Infect. Control Hosp. Epidemiol. 2016;37(4):493–494